Systems change is really hard

I read a couple of good articles today that reminded again of the barriers to systems change. This is in health care of course, but the same thing is true in other areas. After all, why don't we have electric car charging stations as common as gas stations? It's multifaceted of course but one major reason is that would require reshaping the energy delivery system for a major component of daily life. You can't just build a new and ideal world from scratch...we have to get there from here and live every day of the journey too. The fancy academic term for it is path dependence.

Here's a piece in The Atlantic about a doctor and videographer trying to accomplish revolutionary change in health care delivery by showing us what extreme medical interventions really are like for the recipients. He's using short (so they can be shown on a tablet in a doctor's office or hospital) and deliberately banal to share information but avoid emotional manipulation. Jonathan Rauch (the writer  describes health care a "impervious to disruptive innovation...more than any other nongovernmental sector." But he simultaneously notes that the health care system itself must learn to harness the energy of these innovators or it will fail. And I might add that the longer we go before finding a way to change, the more abrupt and wrenching that change will be when it occurs.

Ezra Klein wrote about one systems intervention in Pennsylvania that has shown this type of success. (Aaron Carroll weighs in too.) But the program is now at risk of losing the Medicare funding that's sustained it for the last decade, in part because there is little place for low-tech communication and personal visits in the current health care system. Health Quality Partners has reduced hospitalizations by 33% and cut Medicare costs by 22%. The problem is this intervention (weekly nurse visits to help with maintenance for high-risk elderly people) requires changes in the systems and processes that deliver care. A new drug on the other hand fits neatly into the existing delivery system, you just add a new name to the prescription repertoire and a new code in the electronic ordering system. That's something that could scale up quickly and easily. On the other hand it's not very easy to get more hospitals to lead an intervention that would cut one fifth of their business. That's a lot of money and a lot of people's livelihoods and a lot of changes in the way we are accustomed to doing things.

I hope we can get there one step at a time though. So if you or a friend or a loved one are facing a lot of medical interventions and maybe terminal illness ask your doctor to take time for The Conversation about what kinds of treatment you really want and what your goals are for the remainder of your life. Otherwise you risk the system defaults which will give you a lot of unwanted and often unpleasant medical interventions. And ask what care coordination assistance they can offer. As Quality Health Partners shows that can go a lot further to keep you living at home than all the pills and surgeries we can offer.